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Business Names in Colorado

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					Waste Tire Facility Registration Application
NOTE: Pursuant to §25-15-201, et seq, of the Colorado Revised Statutes (C.R.S.), and Section 10
of the Colorado Solid Waste regulations (6 CCR 1007-2, Part 1), all waste tire haulers and waste tire
facilities are required to register with the Department by submitting a completed version of this
form. For companies with more than one location, each location must be separately registered.

Business Name

Other Business Names (DBAs)

Mailing Address                                                 City                                  State            Zip Code
                                                                                                      CO
Street Address                                                  City                                  State            Zip Code
                                                                                                      CO
Business Phone No.                                              Business E-mail Address

Business Owner (Owner, CEO, President, etc.)                    Owner Business Phone No.              Owner Cell Phone No.

Business Manager (local)                                        Manager Business Phone No.            Mgr Cell Phone No.

Principle Contact Person (local POC)                            POC Business Phone No.                POC Cell Phone No.

POC E-mail Address                                                                                    .

Type of registration                                  Waste tire retailer or wholesaler                   Waste tire hauler
(Mark “X” next to all that apply)
                                                      Waste tire end user                                 Waste tire processor

                                                      Waste tire collection facility                      Waste tire monofill

                                                      Other – specify:
For Waste tire haulers ONLY:
A legible copy of the current surety bond or other financial assurance document must accompany this registration.
Number of vehicles to be used to transport waste tires          (number of vehicle decals needed at 1 decal/vehicle)
For each vehicle, the following information must accompany this registration:
    1. A legible copy of the current vehicle registration showing state of registration, year, make, tag number, vehicle
         identification number, and registered owner.
    2. If the vehicle is not owned by the waste tire hauler, and authorization from the vehicle owner for the vehicle to be
         registered for waste tire hauling

I certify that the information on this application is true and correct to the best of my knowledge.
Please insert an electronic signature
in the box to the right and e-mail completed
form to: cdphe.xxxx@state.co.us
(Subject Line: Waste Tire Registration)
                                                           Signature:
If you are unable to provide an electronic
signature, please print, sign, and mail to:
                                                                             Date:
Solid Waste Program
Colorado Department of Public Health and Environment
HMWMD-B2
4300 Cherry Creek Drive South
Denver, CO, 80246-1530

				
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